Is carbamazepine safe to take during pregnancy?

Question Some of my pregnant patients are afraid to take their antiepileptic drugs during pregnancy because of the known risk of malformations and the neurodevelopmental problems associated with valproic acid. Are there similar concerns with carbamazepine?Answer Similar to valproic acid, carbamazepine increases the risk of neural tube defects; however, it does not increase the risk of other malformations. Carbamazepine is also not associated with an increased risk of developmental delay.     

Is ondansetron safe for use during pregnancy?

Question While I usually prescribe doxylamine-pyridoxine for morning sickness, some of my patients with severe nausea and vomiting of pregnancy (NVP) receive ondansetron in hospital. I have read some new precautions recommended by the US Food and Drug Administration (FDA). Is ondansetron safe to use during pregnancy?Answer During the past decade ondansetron has been increasingly used in the United States for NVP, owing to the lack of an FDA-approved drug for this condition. While fetal safety data for doxylamine-pyridoxine are based on more than a quarter of a million pregnancies, the fetal safety data for ondansetron are based on fewer than 200 births. Moreover, a recent case-control study suggested there was an increased risk of cleft palate associated with ondansetron. Recently, the FDA issued a warning about potentially serious QT prolongation and torsade de pointes associated with ondansetron use; the warning included a list of precautions and tests that must be followed. The drug is not labeled for use in NVP in either the United States or Canada. Based on the data available today, ondansetron use cannot be assumed to be safe during pregnancy.     

Taking ACE inhibitors during early pregnancy: Is it safe?

QUESTION I knew that angiotensin-converting enzyme (ACE) inhibitors were risky to use during late pregnancy because they can cause renal shutdown in the fetus. Recently I heard of a study that claimed first-trimester exposure (when many patients still are unaware of their pregnancies) can also cause major malformations. Is this proven?ANSWER A recent study did suggest an increased risk of malformations after first-trimester exposure to ACE inhibitors among women treated for hypertension. We believe this study had serious limitations that preclude drawing any conclusions at present.     

Is air travel in pregnancy safe?

QUESTION: How should I advise the increasing number of my pregnant patients who need to fly as part of their jobs? ANSWER: Overall, existing data do not confirm increased reproductive risks for otherwise healthy pregnant women traveling by air. Pregnant women with specific medical conditions that might be exacerbated by a hypoxic environment, such as respiratory and cardiac diseases, should avoid flying, as should women at risk for preterm labour and those with placental pathologies.     

Are probiotics safe for use during pregnancy and lactation?

QUESTION: There has been a great deal of discussion in both the medical and lay literature about the use of probiotics to improve general health. Subsequently, pregnant women have been asking me if probiotics used for treating conditions such as bacterial vaginosis and diarrhea are safe to use during pregnancy and lactation. ANSWER: Current data suggest that probiotic supplementation is rarely systemically absorbed when used by healthy individuals. One meta-analysis and several randomized controlled trials conducted with women during the third trimester of pregnancy did not report an increase in adverse fetal outcomes. There have been no published studies addressing Saccharomyces species use in pregnancy. Probiotics are unlikely to be transferred into breast milk.     

Is thrombolytic therapy safe during active menstruation?

A 39-year-old female presented to the Emergency Department during the fourth day of menstruation and within 2 hours of the onset of chest pain associated with dyspnea, diaphoresis, and emesis. An electrocardiogram showed acute inferior myocardial infarction and serial CPK enzyme levels peaked at 958 IU/L with 9% MB fraction. Along with aspirin and intravenous nitroglycerin, the patient was given thrombolytic therapy consisting of tPA with an initial bolus of 35 units, followed by 65 units infused within 60 minutes together with heparin 5000 units intravenous bolus, and 1000 units/hour maintenance infusion for 5 days. The menses were prolonged 1 day longer than her usual 5 days; however, there was no increase in the amount of bleeding during any day. The hemoglobin dropped from 12.5 G/dl to 11.3 G/dl in the first 6 hours, but remained stable thereafter. This initial drop in hemoglobin was considered a dilutional effect of 1.5 L of normal saline the patient received intravenously during that period. Although no available guidelines exist regarding the safety of thrombolytic agents during active menstruation, this case report and a few others reported in the literature suggest that normal menstruation is not a contraindication to thrombolytic therapy during acute myocardial infarction.     

Is it safe to use inhaled corticosteroids in pregnancy?

Question A healthy woman with mild to moderate asthma came to my clinic today after learning that she was pregnant. She inquired about continuing her inhaled corticosteroid (ICS) medication and whether there would be any risks to her unborn child if she were to do so. What would you advise?Answer Given the published evidence, ICSs should be continued throughout pregnancy at low to moderate doses sufficient to control asthma symptoms and prevent exacerbations. However, caution must be taken with doses greater than 1000 µg/d (chlorofluorocarbon beclomethasone equivalent), although whether such doses cause adverse effects is currently still questionable. Patient education on proper ICS administration and adherence, including during the first trimester, must be ongoing. Well controlled asthma will reduce the need for higher ICS doses and possible exposure to systemic corticosteroids, and might decrease the risk of adverse pregnancy or perinatal outcomes.Asthma is a chronic inflammatory disease that frequently results in bronchial obstruction with symptoms of dyspnea and coughing.¹ It affects up to 8.4% of pregnant women in the United States² and, if uncontrolled, can lead to decreased fetal oxygen supply.¹ Popular inhaled corticosteroids (ICSs) currently available globally include budesonide, fluticasone propionate, beclomethasone dipropionate, triamcinolone acetonide, flunisolide, mometasone furoate, and ciclesonide.¹ To date, the number of adequately controlled studies on ICS use during pregnancy is still small. The newer ICSs, mometasone and ciclesonide, have not yet been studied in pregnancy.     

Is normal pregnancy atherogenic?

Serum cholesterol, triacylglycerols and low-density lipoprotein (LDL) subfractions were determined in 120 primagravid women during normal gestation (40 in each trimester) and in 20 non-pregnant age-matched controls. LDL subfractions were determined by PAGE, and an LDL score was calculated. The higher the score, the smaller the subfractions. The objective of the study was to determine the effects of the hyperlipidaemia, high oestrogen concentrations and insulin resistance known to exist in normal pregnancy on LDL subfraction formation. Pregnant women had an increased mean serum cholesterol concentration [5.78 (S.D. 1.09) mmol/l] in the first trimester compared with the non-pregnant controls [5.11 (0.77) mmol/l; P<0.01]. The serum cholesterol concentration increased progressively throughout gestation to a mean of 8.14 (1.39) mmol/l in the third trimester (P<0.001 compared with the second trimester). Triacylglycerol concentrations in the first trimester were similar to those of controls, and there was a non-significant increase by the second trimester to 1.32 (0.44) mmol/l. However, by the third trimester the mean triacylglycerol concentration had doubled [2.58 (0.98) mmol/l; P<0.001 compared with the first and second trimester]. During gestation the LDL score increased dramatically, from 1.17 (0.39) during the first trimester to 2.01 (0.37) in the second trimester (P<0.001) to 2.73 (0.48) in the third trimester (P<0.001 compared with the second trimester). Thus an atherogenic lipid profile develops during normal gestation. The significance of these changes remains unclear, but thay may have important implications for mother and foetus.